Challenges and opportunities to provide immunization services: Analysis of data from a cross‐sectional study on a sample of pharmacists in a developing country

Abstract Background and Aims Vaccine‐preventable illnesses continue to be a global health concern as immunization coverage remains below its targets. National plans emphasize on the essential role of multidisciplinary efforts and approaches to vaccination programs. Pharmacists are globally getting involved in immunization services as important members of the healthcare team. This study aimed to determine barriers, and assess challenges and possible opportunities to provide immunization in the Lebanese pharmacy practice. Methods This was a cross‐sectional study that included pharmacists from all over Lebanon, as part of a national research to assess the role of pharmacists as immunizers. All registered pharmacists in Lebanon practicing in community, hospital, or other clinical settings were considered eligible for participation. A web‐based self‐administered validated questionnaire, which is initially developed by the American Pharmacists Association, was adapted with permission. Results A total of 315 pharmacists responded to the survey. Only 23.1% declared completing an immunization training program. Over half of pharmacists (58.4%) administer vaccines to patients. A significant association between lack of support from physicians to pharmacists (adjusted odds ratio [ORa] = 2.099, 95% confidence interval [CI] = 1.290–3.414, p = 0.003) and vaccine administration was found, while cost associated with professional development and additional training (ORa = 0.533, 95% CI = 0.287–0.989, p = 0.046) was inversely associated to it. Logistic, financial, and legislative requirements as essential necessities were determined to successfully expand pharmacist‐led immunization services. Conclusions The major barriers and challenges to vaccine administration by pharmacists comprised a lack of physicians' support and expenses associated with professional development and additional training. Pharmacists administer more vaccination despite lack of support from physicians; whereas they administer less vaccination due to cost associated with professional development and further training. The scope of pharmacy practice in Lebanon is not well recognized by other healthcare providers and stakeholders to include immunization services.

training. The scope of pharmacy practice in Lebanon is not well recognized by other healthcare providers and stakeholders to include immunization services.

K E Y W O R D S
barriers, experience, immunization, pharmacists, vaccines

| INTRODUCTION
Vaccination is one of the safest, most effective and economically proficient measures to prevent, eradicate and control life-threatening infections. 1 Vaccines are simply defined as biological substances that stimulate the development of immunoglobulins to protect against a disease. 2 In fact, ordinary infections were a primary cause of global mortality before the introduction of vaccines. 3,4 The annual mortality prevention due to immunization is projected to be between 2 and 3 million deaths. 5 There is a strong evidence that national immunization programs have a significant effect on the prevalence of infectious diseases. 6 In the developed countries, immunization programs, and easier access to vaccination services have led to a very low rates of vaccine-preventable illnesses. 7 Nevertheless, vaccinepreventable illnesses continue to be a global health concern as immunization coverage remains below its targets. [8][9][10] To fully address this issue, national plans emphasize on the essential role of multidisciplinary efforts and approaches to vaccination programs.
Healthcare professionals, principally primary care providers and pediatricians, are requested to collaborate in immunization programs to disseminate evidence-based information about vaccines safety and efficacy, as well as the risks of vaccine-preventable conditions. 11 The role of pharmacists is constantly evolving as they are globally getting involved in immunization services in addition to being drug specialists, first-line healthcare practitioners, and important members of the healthcare team. [12][13][14] During the last 5 years, the International Pharmaceutical Federation (FIP) has led various surveys and produced several reports. The 2020 report revealed that the number of responses to its vaccination surveys has doubled since its last dissemination among its member organizations, indicating that the process of pharmacist involvement in vaccination is progressing. 15 Moreover, a pharmacist recommendation to obtain immunization has been found to have a beneficial influence on a person's decision to become vaccinated. 16 Pharmacists can increase vaccination uptake by playing the role of an educator, facilitator, and administrator and thus improving vaccine confidence and coverage in the community. 17,18 In the United States (US), pharmacist immunizers have verified the pursued benefits reinforcing the expansion of pharmacy practice to incorporate immunization. [19][20][21] Although they encountered challenges and several barriers to administer vaccines relating to logistics and financial resources. [22][23][24] On the other hand, important facilities were recognized including managerial and training support, and additional human resources to provide vaccination in the practice settings. 25 Lebanon is a developing low-middle-income country that is located in the Middle East region. 26 The role of pharmacists as immunizers is still controversial and very limited data are available. 27 The FIP reported in 2016 that Lebanese pharmacists do not tend to promote immunization, and initiatives around vaccination generally focus on the seasonal flu vaccine. In addition, patient awareness and promotion campaigns are very limited with a lack of national pharmacy-immunization awareness campaigns. 28 This is possibly attributed to major challenges and barriers, and lack of legislation updates on the scope of Lebanese pharmacy practice to include immunization services. This study aimed to determine barriers, and assess challenges and possible opportunities to provide immunization in the Lebanese pharmacy practice.

| Study design and participants
This was a cross-sectional study that included pharmacists from all over Lebanon, as part of a national research to assess the role of pharmacists as immunizers. Data were collected through a snowball sampling technique utilizing an electronic questionnaire. To collect a sample from different districts all over Lebanon, the questionnaire was also shared on the Order of Pharmacists of Lebanon smart phone application with all registered pharmacists. The questionnaire form included a cover section with detailed information to explain the objective and context of the study. All registered pharmacists in Lebanon practicing in community, hospital or other clinical settings were considered eligible for participation. The pharmacists needed around 20 min time to complete the questionnaire.

| Questionnaire and outcomes
A web-based self-administered validated questionnaire that is initially developed by the American Pharmacists Association was adapted with permission. 29 Reliability testing was performed. The internal consistency of the questionnaire showed a good Cronbach's alpha of 0.717 among our sample. 30 A total of 50 questions were included over 5 parts of the questionnaire. The first part involved the sociodemographic characteristics of pharmacists. The second part assessed whether the pharmacist has completed an injection and immunization training program or not. Pharmacists who completed any immunization training program were asked about their level of confidence to provide vaccination based on the certificate they acquired. They were also asked about what should be added for these programs to better prepare pharmacists for providing immunization. Pharmacists who did not complete any immunization training program were asked about their willingness to complete any of these training programs in the future.
The third part included questions about services offered at the participant's pharmacy. This part identified barriers to provide immunization in pharmacy practice. It allowed the participant to select all options that apply around reimbursement concerns, lack of pharmacy space to store and/or to administer vaccines, lack of support from management and/or physicians, time needed for professional development or additional training, costs associated with professional development and/or additional training, liability and malpractice concerns, personal belief that it would not serve the public, insufficient man power, lack of confidence about recognizing adverse events following immunization, lack of knowledge to manage adverse events following immunization, record keeping, and personal thoughts that the benefits do not outweigh the risks.
In the fourth part, immunization services provided by the pharmacist including vaccine administration (type, frequency, and duration of providing this service), patient education, and management of adverse events were assessed. The fifth part included questions about recognition for immunization services. Five-point Likert scales were used to assess pharmacist recognition by other healthcare providers, public health stakeholders and patients as an immunizer; as well as the pharmacists' beliefs about the needs that should be addressed to expand successfully the immunization services provided.

| Sample size calculation
The minimum sample size was calculated using CDC's Epi Info version 7.2.4. for population surveys. The expected frequency that yields the larges sample size was used to allow for adequate power of statistical analysis, and to produce a 95% confidence level with an acceptable margin of error of 5%. A minimum of 240 participants were required to assess barriers in providing immunization services based on expected frequency of 80%. 29 This minimal size allowed to assess for the additional outcomes as they had expected frequencies between 90% and 93%, and therefore required a smaller sample size to be evaluated.

| Ethical aspect
The Ethics and Research Committee of the School of Pharmacy at the Lebanese International University approved the protocol (2020RC-033-LIUSOP approved December 9, 2020). Informed consent was obtained by all participants, as they should have agreed to participate before being able to fill the survey. believe that the current program is sufficient to prepare pharmacists, and 45.9% believe that the program can be expanded by live day workshops to better prepare pharmacists to provide immunization.

| Statistical analysis
The majority of participants (75.2%) also appear to be up-to-date with their personal immunization, and 78.7% receive the annual influenza vaccine. Table 1 reports the detailed experiences and perception of pharmacists related to immunization, and immunization services.  (Table 1).

| Barriers to providing immunization
The major barrier to provide immunization was lack of support from physicians to pharmacists, perceived by over half of the pharmacists

| Bivariate analysis of barriers on administering vaccination in pharmacy practice
There was a significant positive association between lack of support from physicians and the frequency of vaccine administration (66.7%) T A B L E 1 Experiences and perception of pharmacists related to immunization, and immunization services.
Completion of immunization training program   Table 2.

| Multivariable analysis of barriers on administering vaccination in pharmacy practice
There was a significant association between lack of support from physicians and cost associated with professional development and  (Table 3).

| Recognition of pharmacists as immunizers and expansion of their role
Less than one-third of pharmacists (28.5% agree to strongly agree) felt that they are fully accepted by the local public health authorities as immunization providers. Around one-quarter (  We found that seasonal influenza vaccination is the main immunization service provided to the community by pharmacists.
Most pharmacies provide walk-in immunization services during the flu shot season. Although pharmacists are not reimbursed for this service as the patient usually self-pay for the vaccine product with no additional cost for the service. Isenor and colleagues also found that seasonal influenza vaccine is the most frequently administered vaccination in New Brunswick, Canada. 29 However, the Canadian pharmacists are reimbursed for influenza immunization services within a publicly financed immunization program. 31 In addition, pharmacists frequently administer several vaccines including pneumococcal, herpes zoster, and Hepatitis A and B, all of which are patient self-paid or covered by private insurance. 29,32 This study found that the most frequently perceived barriers in the provision of immunization are related to limited support, logistics and resources. Surprisingly, we found a significant positive association between lack of support from physicians and vaccine administration. Pharmacists who perceive lack of physicians' support as a substantial barrier were administering more vaccines compared to other pharmacists. This finding could be the result of ongoing debate and conflicts between local physicians and pharmacists on the scope of practice and the authority to provide immunization. 33  We also found a negative association between costs that are associated with professional development and additional training, and vaccine administration. Our results are consistent with other findings that reported financial resources as a principal barrier in providing vaccination services. In addition to restricted access to publicly financed vaccines, lack of well-trained pharmacy staff, and space limitations. [22][23][24]32 In fact, challenges relating to the vaccination systems and processes have been globally addressed. Recommendations to overcome such barriers focus on enhancing the vaccination infrastructure, 34 upgrading legislation and vaccination policies, 35 obtaining political commitment to enhance vaccine regulation, 36 implementing fair reimbursement systems, 37 and enhancing and strengthening vaccination surveillance systems. 35,38,39 Over half of the pharmacists perceive themselves completely recognized as immunizer by patients. This is justified by the high frequency of educational activities that Lebanese pharmacists offer to the public around immunization. Similar findings were reported by a public survey on the potential pharmacists' role as immunizers. 40 The qualification of being a pharmacist could provide initial aptitude for vaccination provision, although a previous study from Lebanon providing a great opportunity to extend and enhance access to medication and vaccination. 42 Another important opportunity to the pharmacists and benefit to the public are the convenient operating hours of community pharmacies, which may be highly appealing to both working and nonworking people. 43 This is especially essential in rural, remote, and medically underserved regions, where access to vaccination centers might be difficult. 28,44 In the United States, vaccination rates doubled among young adults after 10 years of implementing pharmacy-based vaccination, highlighting the benefits of the service provided. 45   However, it is believed that this bias is minimized as the sample was collected from different districts all over Lebanon. Last, the study included young pharmacists mainly, therefore the findings cannot be generalized for senior pharmacists.

| CONCLUSIONS
Pharmacists in Lebanon are active contributors to immunization services. They are well positioned in the community to perceive themselves supported by patients for this role. Nevertheless, the scope of pharmacy practice is not recognized by other healthcare providers and stakeholders to include immunization services. The major barriers to vaccine administration by pharmacists comprised lack of physicians' support and expenses associated with professional development and additional training. Pharmacists administer more vaccination with the lack of support from physicians; whereas they administer less vaccination due to cost associated with professional development and further training. Additional research is suggested in this scope to determine the mediator role of practice challenges on the provision of immunization, and to provide barrier-tailored recommendations to overcome the encountered difficulties. conceptualization; resources; supervision.

ACKNOWLEDGMENTS
The authors would like to thank all pharmacists who participated in this research. This work did not receive any funds.